Program for 8th International Surgical Sleep Society Meeting Los Angeles, CA in May 2017

Keck Hospital of USC is ranked among the best hospitals in the country in the US News and World Report "Best Hospitals" listDr. Kezirian is consistently ranked as a top doctor by numerous Top Doctors websites, Healthgrades, Best Doctors in America, and many other organizations and publications.

The tongue is an essential part of our body, but in many patients with sleep apnea the tongue can be so large that it blocks off the breathing passage during sleep. This is particularly true as people gain weight, as fat is deposited inside the tongue to make it larger. In some cases, it may be beneficial to remove a portion of the back of the tongue with a procedure called midline glossectomy or submucosal lingualplasty. The midline glossectomy procedure was developed 20 years ago but was largely abandoned because of the pain and risks associated with performing the procedure with available technologies, including standard electrocautery and laser. Newer technologies (such as Coblation) reduce the pain and the risks to nerves and blood vessels that travel on the sides of the tongue. These technologies have also allowed a more-complete removal of tongue tissue with a procedure called submucosal lingualplasty.

How is midline glossectomy sleep apnea surgery performed?

This procedure is performed in the operating room under general anesthesia, and it is performed by working through the open mouth without any external incisions except a small one on the neck for a plastic drain placed at the time of surgery. After using ultrasound to trace out the location of the major blood vessels on the sides of the tongue (with the nerves even farther towards the sides), a central portion of the middle and back of the tongue is removed. The major blood vessels and nerves are then protected, and some additional parts of the tongue are then also removed. Stitches are placed to close everything together after a plastic drain is placed inside the tongue where the surgery is performed.

Preoperative: enlarged tongue with blue lines showing the major blood vessels of the tongue and shaded lines showing the major portion of the tongue that is removed

Postoperative: tongue reduced in size and no longer overlapping the teeth of the lower jaw (mandible) and with sutures in place

The following video presents a discussion of Tongue Region procedures, including midline glossectomy:

RISKS

Bleeding
As with any procedure, there is a risk of bleeding. Bleeding in this area can be serious and life-threatening. Fortunately, this is uncommon, and usually there is only minor oozing or blood-tinged mucus. A major factor in preventing serious bleeding is to avoid the use of aspirin, NSAIDs (such as ibuprofen, Advil®, Motrin®, naproxen, or Aleve®), vitamin supplements, or herbal medications for three weeks before and after surgery.

Infection
To reduce the risk of infection, an oral antiseptic rinse is used—and antibiotics givenprior to the procedure. With these precautions, the risk of infection is low, but tongue infections can also be serious and life-threatening.

Tongue numbness or tingling
There is a nerve (lingual nerve) that is responsible for the senses of touch and taste for the tongue. Midline glossectomy involves use of a unique type of radiofrequency (heat) energy on the tongue, and this can produce nerve damage. This nerve is located within the bulk of the tongue along the sides, and therefore midline glossectomy are performed more thoroughly in the central part of the tongue. If nerve damage or these symptoms do occur, usually the damage is temporary with recovery over the course of days or weeks, but the damage can take months to recover or be permanent.

Tongue weakness or trouble swallowing
A second nerve (hypoglossal nerve) on each side of the tongue is responsible for tongue movement. It also can be injured during midline glossectomy, but the same precautions reduce the risk of injury as for the lingual nerve (described directly above). The tongue is important for swallowing and either nerve injury or the swelling that occurs after a tongue procedure can present some difficulty with swallowing. a If damage does occur, this should recover over the course of days or weeks, but the damage can take months to recover or be permanent.

Tooth injury
Operating in the back of the throat is impossible unless an instrument is placed to keep the mouth open. This is the same instrument used when tonsillectomies are done. Rarely, a tooth may be injured by this instrument, and the risk is much higher if a tooth is loose or decayed prior to surgery.

Need for additional procedures
Midline glossectomy may not be effective in accomplishing the goals of surgery. Another procedureeither performed on the tongue region or on another areamay be necessary.

POSTOPERATIVE INSTRUCTIONS

NOTIFY DR. KEZIRIAN IMMEDIATELY IF YOU HAVE ANY TROUBLE BREATHING OR IF ANY BLEEDING DEVELOPS!

Hospital stay and discharge
Most patients stay in the hospital 1-2 days. The major concerns while you are in the hospital are making sure you are breathing freely, having no bleeding, controlling your pain with oral medications, and drinking enough fluids to have no risk of dehydration. Many people ask if they need someone to stay with them at home. You do need someone to stay with you the first night home after discharge, for safety. Beyond that, it is helpful to have someone available and checking on you to provide assistance when needed, although they do not have to stay with you 24 hours a day, every day. Planning before surgery (for example, buying milk or nutritional supplements) will decrease the amount of help you need at home after surgery.

Pain control
Like most surgeries, there is pain in the recovery period. However, we want to control your pain to make you comfortable during your recovery. Some people try to “hang in there” or suffer without taking pain medications. Controlling your pain is important for breathing, healing, and being able to swallow enough to maintain your nutrition. You will not receive a prescription for pain medications before surgery, as we will send you home with the type of medication and the amount that worked well for you in the hospital.

While in the hospital, we will control your pain with oral medications, starting on the day of surgery. You can also hold ice chips inside your mouth to decrease swelling and reduce pain. Although we will use intravenous pain medications if necessary, the goal will be to use oral medications alone because this is what you will use when you go home after surgery. You will not receive a prescription for pain medications before surgery, as we will send you home with the type of medication and the amount that worked well for you in the hospital.

When you are at home, take your pain medication as you need it. You can also continue to hold ice chips inside your mouth to decrease pain and swelling. Try not to let the pain increase until it becomes intolerable before you take the medication. If you are running out of medication and need more, please call the office in advance to obtain another prescription. If you prefer to avoid narcotics, you should feel free to use acetaminophen (Tylenol®). Avoid aspirin, NSAIDs (such as ibuprofen, Advil®, Motrin®, naproxen, or Aleve®), vitamin supplements, or herbal medications for at least two weeks because they can increase your risk of bleeding after surgery. Your pain will be significant for at least the first 7-10 days following surgery, but it should improve markedly by 14 days following surgery.

Nutrition and fluids
It is very important to have good nutrition and avoid dehydration after surgery. Due to the pain and swelling that is expected after surgery, you will most likely only be able to tolerate a liquid diet for the first 4-5 days after surgery. Push yourself to drink fluids, even if it is painful. The first sign of dehydration is a decrease in urination, so keep track of this. In addition to water, it is It is helpful to drink other liquids, such as juices or Gatorade®. It is also essential that your body receive protein and fat in your diet to help with healing and maintaining your energy level. Every day, you should have 3 glasses of something with fat and protein like milk or chocolate milk, nutritional supplements like Muscle Milk® or Ensure®, or protein shakes. Dr. Kezirian may order a nutritional supplement like this while you are in the hospital. As your recovery continues, you will transition to soft solid foods such as eggs, yogurt, or mashed potatoes. You should be able to tolerate a fairly normal diet by 2 weeks after surgery. During the recovery period, you should avoid foods with sharp edges such as chips because these can cause bleeding. Otherwise, you can advance your diet according to your own schedule, being careful not to cause too much pain. Dr. Kezirian wants his patients to maintain their nutrition so that they do not lose weight in the few weeks right after surgery.

Antibiotics
Most patients receive an antibiotic while in the hospital. You may be prescribed an antibiotic to take when you go home. This can be useful for preventing infection and decreasing swelling. Take the antibiotics as directed. If you develop a rash or diarrhea (possible risks of antibiotics and other medications), stop the antibiotics and contact Dr. Kezirian immediately.

Activity
Walking after surgery is important. Patients should walk at least 3 times a day starting the day after surgery. Walking helps prevent blood clots from forming in your legs. Spending more time out of bed (walking or in a chair) than in bed is helpful because your lungs fill up with air, lowering the risk of fevers and pneumonia. Not walking enough is a major cause of fevers after surgery, so please do remember to walk at least 3 times every day. Patients should avoid strenuous activity for 4 weeks following surgery because that typically raises heart rate and blood pressure. For this reason, it can increase swelling or cause bleeding to start.

Do not use mouthwashes, lozenges, or throat sprays Patients should not use mouthwashes, lozenges, or throat sprays following surgery because many of these contain alcohol that can irritate the lining of the mouth or numbing medication that can expose you to a serious complication when used for more than a couple of times.

Ear problems or jaw discomfort
The swelling in your throat that occurs after surgery can cause jaw pain or ear symptoms such as pain, pressure, or fullness. This is common and should improve within 1-2 weeks following surgery. It occurs because the soft palate and tonsils are next to the jaw and the small Eustachian tube that connects the space behind the eardrum to the top of the throat. Swelling in the throat can interfere with your ability to clear or pop your ears, and it can also be sensed by your body as pain coming from your ears even though the ears are not affected (a phenomenon called referred pain).

Sleep with head elevated (at 45 degrees) for at least three days
Elevating your head during sleep decreases blood flow to the head and neck regions. Therefore, it decreases swelling and the associated pain. Elevating the head during sleep may also improve breathing patterns in other ways. Therefore, we recommend elevating your head during sleep at 45 degrees for at least three days following the procedure.

Nausea and constipation
Nausea and constipation are very common after any surgery. The anesthetic medications that you receive during surgery and the narcotic pain medication you receive after surgery can cause these. You will receive medications after surgery to decrease nausea and constipation, but please notify Dr. Kezirian if you feel constipated or have not had a bowel movement in any 3 days after surgery.

Postoperative appointment
Dr. Kezirian likes to see his patients 1-2 weeks after surgery. If a postoperative appointment has not been scheduled, please contact the office at 323-442-5790 to schedule this when you return home after your surgery.

Additional questions
Please call the Nurse line at 323-442-0190 with any questions during normal business hours. For after hours or weekends, please call the Call Center at 323-442-5790 to speak to the physician on call.